J Clin Aesthet Dermatol. 2024;17(12):38–41.
by Evgeniya Shelemba, MD, PhD, and Elena Rumyantseva Mathey, MD, PhD
Dr. Shelemba is with P.L. Shupik National Medical Academy of Post-Graduate Education in Kyivska, Ukraine. Dr. Mathey is with the International Master Course on Aging Science in Paris, France.
ABSTRACT: Background: Intradermal injections of highly diluted botulinic neuroprotein is a popular aesthetic medicine procedure to improve the texture of the skin, enlarged pores, and fine lines.
Objective: The authors present a case report of nine subjects who received treatment with botulinic neuroprotein combined with an amino acid cluster and low molecular weight hyaluronic acid.
Methods: Nine women between the ages of 30 to 59 years old in a stable medical condition with moderate to severe lateral cantal wrinkles and smile lines at maximum expression and were recruited. The typical exclusion criteria for botulinum neurotoxin and hyaluronic acid injections were fulfilled.
Results: No complications were observed. In all treated patients, there was clinical improvement in skin surface and texture, as well as attenuation of fine lines, with preserved natural facial mimetic activity. In two patients who were prone to rosacea, we noticed an improvement in erythema and flushing. Three patients with oily skin showed decreased oiliness and pore size.
Conclusion: The Jalu-toxin technique is a safe and efficient method for skin quality enhancement.
Keywords: Botulinum toxins, micro-botox, meso-botox, intradermal botulinum toxin injection, amino acid replacement therapy, hyaluronic acid, extracellular matrix
Introduction
Intradermal injections of highly diluted botulinum neurotoxin are commonly used in aesthetic medicine procedures that improve the texture of the skin, enlarged pores, fine lines, and rosacea symptoms. The role of acetylcholine in production of sebum and development of rosacea is becoming more evident, implying that botulinum neurotoxin inhibits some rosacea, acne, and fine lines pathogenetic components.7 This study aims to explore the efficacy of combining botulinic neuroprotein with an amino acid cluster and low molecular weight hyaluronic acid injected according to a specific technique, termed here as the “Jalu-toxin” technique.
The Jalu-toxin technique, in conjunction with an amino acid cluster, has been developed to reduce fine lines and improve skin texture using a series of small microdroplet injections. Precise injections of highly diluted botulinic neuroprotein, combined with low molecular weight hyaluronic acid and a cluster of lyophilized amino acids, into the deep dermis or superficially subdermally are meant to target only superficial muscle fibers at the level of their insertion into the dermis.
This injection technique is less likely to lead to the diffusion of neurotoxins into deep muscles and cause undesired effects, allowing the treatment of areas that are generally avoided with on-label injection techniques, such as fine lines in the periorbital area, cheeks, and neck.3,4
Low-molecular-weight hyaluronic acid, apart from its hydrating and extracellular matrix-regulating properties, acts as a viscosity modifier, preventing quick diffusion of the botulinum toxin solution. Amino acids are the building blocks of collagen production, which causes fibroblast chemotaxis to the injected area and stimulates neocollagenesis, thus improving skin thickness, elasticity, and texture.1 Diluted botulinum neuroprotein, injected into tiny microdroplets, targets the superficial muscle fibers at the level of insertion into the dermis, decreasing fine lines and improving skin texture. Thus, Jalu-toxin combines the effects of meso-botox, hyaluronic acid, and amino acids, in one injection.
In this preliminary assessment of this technique, the authors present a case report of nine subjects in whom the Jalu-toxin technique was performed.
Methods
Nine women between the ages of 30 to 59 years old in a stable medical condition with moderate to severe-degree lateral cantal wrinkles and smile lines at maximum expression were recruited. The typical exclusion criteria for botulinum neurotoxin (BTX) and hyaluronic acid injections were fulfilled. Informed consent was obtained from all the participants.
Reconstitution of BTX vials and dilution. A 300-unit vial of abobotulinumtoxin A (ABO) was reconstituted with 1.5mL of sterile saline (0.9% isotonic sodium chloride) to obtain a concentration of four units per 0.02mL. For the Jalu-toxin technique, 124 Speywood (Sp) units of abobotulinumtoxin A (Dysport®, Ipsen) were taken into the insulin syringe (0.62mL), and this solution was further diluted with 0.38mL of preservative-free saline directly in the syringe to obtain a total volume of 1mL.
Lyophilized amino acids (total 100mg: glycine, L-proline, L-lysine, L-leucine; Jalupro®, Professional Derma) were mixed with low-molecular-weight non-stabilized hyaluronic acid (LMW HA) (3mL of 1% hyaluronic acid, 200kDa; Jalupro®, Professional Derma) in the vial. It is important to note that we do not mix botulinic neuroprotein with other hyaluronic acid-containing products, because if the viscosity of HA is high, the injection might be performed in the lower layer (not superficially), leading to undesirable diffusion of the product into the muscle. Then, 1mL of meso-toxin was added to the solution into the vial and gently mixed to obtain 4mL of jalu-toxin solution containing 124 Sp units of abobotulinumtoxin A; 31 Sp units were each 1mL.
Injection technique. Marking the areas of injection: Makeup-free patients, while sitting, were asked to practice a forced smile while squinting for the practitioner to be able to mark the continuous dynamic lines that appear on cheeks and in the periorbital area, with the movement of the lateral orbicularis oculi’s part and zygomaticus major muscles. Areas in which these injections should be avoided (Figures 1 and 2) are the lower eyelid (in the borders of the orbit) and above the depressor anguli oris muscle (DAO). The DAO is a large flat triagonal muscle, which lies superficially and can easily be affected by meso-botox injections, causing an asymmetrical smile. In addition, the medial part of the orbicularis oculi lies right under the lower eyelid’s thin skin, so meso-toxin injections in this area can lead to swelling that can last for 2 to 3 weeks, and to ectropion in severe cases.
Following this, we marked the points where it is planned to inject the mixture, an average of 15 to 25 points per each periorbital area and 30 to 50 points per cheek (up to 0.5mL per periorbital area and 0.5mL of Jalu-toxin per cheek, containing up to 15.5 of abobotulinumtoxin toxin). It is recommended not to exceed 50 Sp units of botulinum toxin per side, with no dose limit for hyaluronic acid and amino acids.2 The remaining 2mL of jalu-toxin solution was injected intradermally into the neck area.
We used a 1mL luer lock syringe (to prevent the needle from snapping off) with a 33G 8mm needle. To target the most superficial muscle fibers inserted into the dermis, the needle must be advanced using controlled pressure and the bevel almost parallel to the skin, slowly plunged until a small papule appears on the skin surface. Papules were spread within one hour.
Since the Jalu-toxin technique has been developed to supplement traditional neurotoxin injections, the first procedure is the classic injection of toxin in the forehead and glabella areas, with jalu-toxin administered in the same session or at the two-week follow-up visit.
Evaluation. Photographs were used to evaluate improvements and possible complications during follow-up. Efficacy assessments were performed by both investigators and subjects on Days 14 and 90.
Results
In this case series, we evaluated the effectiveness and safety of combination of amino acids with HA and BTX. This report covers nine patients treated with jalu-toxin, with a follow-up period of three months (Figure 3–6). In total, 45 areas were treated: 18 periorbital areas, 18 cheeks, and nine neck areas.
In all treated patients, there was clinical improvement in skin surface and texture, as well as attenuation of fine lines, with preserved natural facial mimetic activity, either in conjunction with botulinum neuroprotein in classic dilution or without it (Figures 3–6). In two patients who were prone to rosacea, we noticed an improvement in erythema and flushing (Figure 4). Three patients with oily skin showed decreased oiliness and pore size (Figure 5). The effects of jalu-toxin appeared after two weeks and lasted up to three months. No complications were observed.
Discussion
Indications for botulinum toxin injections have evolved tremendously since their introduction in 1989. Numerous studies have suggested the effectiveness of botulinic neuroprotein in treatment of hyperhidrosis, hypertrophic scars, psoriasis, androgenetic alopecia, rosacea, acne, photoaging, and skin texture.
Intradermal uses of botulinum toxin, either hyper-diluted, or mixed with HA and amino acids, have a great deal of potential as a new field of research.
The micro-botox (also called meso-botox method) was developed in 2000 for lower face and neck with the intention of providing results that look more natural. Multiple microdroplet injections of hyper-diluted BoNT-A are used in this method. Meso-toxin is injected into the dermis or subdermally in the micro-papular technique (meaning that a small, blanched weal should be produced at each point), to improve skin texture, soften the dynamic wrinkles, reduce the visibility of vertical bands of the neck, and to enhance mandibular profile. Although this technique was first integrated for ONA, it has been auspiciously implemented with ABO as well. According to Wu,3 however, the results of meso-toxin using ABO are thought to be less reliable, possibly because there are no fixed dose ratios between abobotulinum- and onabotulinum-toxins, and because dose-ranging studies need to be conducted with the technique.3–5
In 2012, Môle et al2 proposed injecting hyper-diluted BoNT-A (ABO) and non-crosslinked HA superficially to treat “accordion lines”, which appear between the orbital rim, temples, and jawline due to a significant midface volume loss and photoaging. The investigator explained the effects of this method on skin quality in the mid-cheek areas by amendment of collagen biosynthesis rates and inflammatory cytokine production as the toxin diffuses into the dermis.2
To prepare the solution, the author recommends mixing 1mL of botulinum toxin diluted as per the instructions, with 1mL of non-crosslinked HA, using the connector. It has been demonstrated that the correct dose is crucial when treating patients with HA and ABO, with low doses not being effective as well as the “frozen” features of some patients as a result of overdosing. Amount of ABO should not exceed 40 units per side, according to authors. Treatment was successful in improving the appearance of “scratched face”, as well as improving the appearance of the “gummy smile” and skin texture. These effects lasted for 4 to 6 months.2
The technique of Jalu-botox was described by Piovano et al.6 Several units of botulinic neuroprotein are injected superficially (supra-, not intramuscularly), to reduce the periorbital, perioral, and horizontal neck lines. Piovano6 suggested using eight units of BoNT-A and 1mL of non-stabilized HA with 100mg of lyophilized amino acids. This protocol was repeated three times over a six-month period.6
The effects of meso-toxin include improvement of fine lines due to the relaxation of superficial muscle fibers, normalization of sebum production in oily skin by interfering with the transmission of cholinergic signals from autonomic nerve endings to sebaceous glands,7 and the symptoms of facial erythema, neck erythema and flushing of the chest have improved. A 2004 study by Carruthers et al8 found that combination of IPL with botulinum neuroprotein improved telangiectasia more than just IPL. It is not fully understood why botulinum neuroproteins reduce erythema, but they may be inhibiting the release of vasodilating neuropeptides.
It was demonstrated in 2014 by Permatasari et al9 that botulinum toxin affects not only skin texture and thickness but also some processes of photoaging. A study conducted in vitro indicates that botulinum neuroprotein significantly inhibits UV-B-induced early senescence in human dermal fibroblasts.10
The technique that was described in this case study allows to obtain “3 in 1 effect” by combining low molecular weight hyaluronic acid, amino acid cluster, and botulinic neuroprotein. The limitation of the study was a small number of patients, and in future we plan to increase the number of patients and perform an objective evaluation of skin with DermaLab skin analyzing machine.
To avoid antibody formation, it is important to perform Jalu-toxin injections in the same session as classic botulinum toxin injection, or at the follow-up session two weeks after. Then the 3 to 4 months interval should be done before the next injection of botulinic neuroprotein.
Limitations. We’ve observed some limitations of the discussed technique, such as the effect of meso-toxin doesn’t last as long as traditional botulinic neuroprotein treatment; this technique requires a skilled practitioner, because the improper technique can lead to complications such as facial asymmetry or ptosis, and, compared to traditional treatment with botulinic neuroprotein, there is less research on the long-term effects and efficacy of meso-toxin. The additional evaluation with a larger number of patients is needed in order to validate the observations derived from the present case series.
Conclusion
As a result of reviewing the literature, applying the proposed technique, and analyzing the results obtained, we believe jalu-toxin offers a safe and successful method for combining botulinum neuroprotein, hyaluronic acid and amino acids.
This technique combines improvement of skin quality by the cluster of amino acids, as well as faster effects of botulinum neuroprotein, such as selective weakening of superficial muscle fibers, which results in less skin tension, and consequently attenuation of fine lines, improved skin surface and texture, and increased skin gloss.
The Jalu-toxin technique is a promising procedure that can be used in conjunction with standard injections. This case series provides insight into the potential of this technique and should serve as a stimulus for larger studies to evaluate the benefits of the jalu-toxin technique for other facial areas and to define the best patient profile for this technique.
References
- Poleva, I. Perioral Rejuvenation: evaluation of safety and efficacy of high molecular weight hyaluronic acid and amino acid treatment. J Drugs Dermatol. 2022;21(9):968–973.
- Môle. B. Griffose faciale: traitement des rides dynamiques du visage par injections dermiques simultanées de toxine botulique A et d’acide hyaluronique. Ann Chir Plast Esthet. 2012;57(3):194–201.
- Wu WTL. Facial rejuvenation without facelifts – personal strategies. Presented at: Regional Conference in Dermatological Laser and Facial Cosmetic Surgery 2002; September 13-15, 2002; Hong Kong, China.
- Wu WTL. Microbotox of the Lower face and neck: evolution of a personal technique and its clinical effects. Plast Reconstr Surg. 2015;136(5):92S–100S.
- Wu WTL. Skin resurfacing with Microbotox and the treatment of keloids. In: Benedetto AV, ed. Botulinum Toxins in Clinical Aesthetic Practice. 2nd ed. New York: Informa Healthcare; 2011.
- Piovano L. Hyalu-Botox in conjunction with amino acid replacement. Prime. 2018;8(2).
- Rho NK, Gil YC. Botulinum Neurotoxin Type A in the Treatment of Facial Seborrhea and Acne: Evidence and a Proposed Mechanism. Toxins (Basel). 2021;13(11):817.
- Carruthers J, Carruthers A. The effect of full-face broadband light treatments alone and in combination with bilateral crow’s feet Botulinum toxin type A chemodenervation. Dermatol Surg. 2004;30(3):355–366.
- Permatasari F, Hu YY, Zhang JA, et al. Anti-photoaging potential of botulinum toxin type a in UVB-induced premature senescence of human dermal fibroblasts in vitro through decreasing senescence-related proteins. J Photochem Photobiol B. 2014;133:115–123.
- Imhof M, Kuhne U. Introduction of the microdroplet technique with incobotulinumtoxin a for the treatment of crow’s feet. J Clin Aesthet Dermatol. 2013;6(7):40–44.